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By W. Georg. University of the Virgin Islands.

Children in the intervention schools reported eating significantly fewer energy-dense snacks per day (–0 buy cialis sublingual on line. These differences were also evident for weekday best buy for cialis sublingual, but not weekend purchase cialis sublingual from india, reporting of energy-dense snacks and negative food markers. The effect of the intervention on reported weekday negative food markers was fully mediated (p = 0. The intervention effect on weekday energy-dense snacks was partially mediated (p = 0. The cost of implementing the intervention was estimated at approximately £210 per child. Costs were predominantly those associated with the time inputs for the HeLP co-ordinator and drama components of the programme. The process evaluation showed that the programme was delivered with a high degree of fidelity in respect of both the components of the intervention and the manner in which the components were delivered. Over 95% of children took part in at least 8 of the 10 sessions of healthy lifestyles week and set goals. Over 90% of children were considered to be actively engaged with the programme according to prespecified criteria, with no differences across socioeconomic groups. Similarly, 75% of parents were considered engaged, and all but three of the schools were deemed to be very engaged and enthusiastic. Parents and children reported changes that they had made to diet and activity, and the majority of barriers to and/or facilitators of achieving goals were related to parental support or lack of it. The schools involved in the trial were broadly similar to those in the south-west and England in terms of socioeconomic deprivation, class sizes and both rural and urban settings, but not in terms of ethnicity. Conclusions HeLP is neither effective nor cost-effective in affecting BMI SDS or preventing overweight and obesity in 9- to 10-year-olds, nor is it effective in increasing physical activity. There is weak evidence of effectiveness in reducing the consumption of unhealthy foods (negative food markers and energy-dense snacks). Future research Our findings show that, although it is an intensive intervention that was able to engage schools, children and their families, HeLP did not affect objectively measured physical activity or weight status. Schools are an obvious location for health promotion programmes but we consider it unlikely that any school-based programme that is not part of a wider co-ordinated whole-systems approach will be able to prevent overweight and obesity in a single age group. Research should address the effectiveness of programmes that incorporate whole-systems approaches. The failure of this intensive intervention, with high levels of engagement, to have a sufficient impact on objectively measured behaviours in children aged 9–10 years still leaves open questions about whether or not it is possible to design effective interventions aimed at very young children whose behaviours may be more malleable or at older children who may have greater autonomy than younger children in making healthy choices. Trial registration The trial is registered as ISRCTN15811706. Funding Funding for this project was provided by the Public Health Research programme of the National Institute for Health Research. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals xxvii provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Currently, one-fifth of boys and girls in England start school overweight or obese, and one-third of children leave primary school (aged 11 years) overweight or obese. School-based obesity preventative interventions have the potential to reach a large number of children and families across the socioeconomic spectrum, and schools provide the organisational, social and communication structures to educate children and parents about healthy lifestyles. Systematic reviews of school-based interventions to prevent obesity and/or increase physical activity and reduce sedentary behaviours show, at best, moderate evidence of effectiveness, with the majority of studies conducted in the USA. Evidence for the effectiveness of school-based obesity prevention programmes In 2012, Khambalia et al. Eight reviews and 112 studies were examined in total, with the most recent literature search conducted in 2008. All eight reviews acknowledged that the studies they included had heterogeneous designs, outcomes and ages of participants. The reviews were judged for their quality, and five were considered to be high quality according to their prespecified criteria. These five reviews included three meta-analyses: Cook-Cottone et al. The other two reviews were qualitative systematic reviews: Brown and Summerbell,11 which assessed the effectiveness of prevention programmes focusing on changing dietary intake and/or physical activity levels in 5- to 18-year-olds; and Kropski et al. However, they did suggest that, given no one single intervention will fit all school populations, further high-quality research needs to focus on identifying specific programme characteristics and approaches predictive of success. Of the 139 intervention studies identified, 115 (83%) were located in the primary school, of which 37 were school-based only. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 1 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. INTRODUCTION activity intervention on weight-related outcomes. The approaches included intensive classroom physical activity lessons led by trained teachers, moderate to vigorous physical activity sessions, nutrition and education materials, and promoting and providing a healthy diet. There was weak evidence that these approaches were effective at reducing body mass index (BMI), BMI standard deviation score (SDS), prevalence of obesity and overweight, percentage body fat, waist circumference and skinfold thickness. Intervention studies that reported a significant effect tended to be of long duration (between 52 and 156 weeks), with the longer-term programmes having the greatest effect. A further 28 studies were school-based with a home component (e. These studies provided moderate evidence of effectiveness, with half reporting statistically significant beneficial intervention effects. However, in all studies, a range of adiposity measures was used and there was high study heterogeneity in terms of setting, design, sample size, characteristics, intervention approach and length of follow-up, which makes cross-comparisons challenging. The review was unable to identify specific programme characteristics and approaches predictive of success or to explore the comparative effectiveness of specific intervention approaches (e. Since the publication of the above reviews, a number of additional evaluations of school-based 13–16 interventions have been published involving children of a similar age to those in the Health Lifestyles Programme (HeLP) study. However, evidence of effectiveness in changing behaviours and/or weight status of children continues to be inconsistent and the content of the intervention varies greatly between studies. In 2010, The Healthy Study Group13 published its findings from a 3-year cluster randomised controlled trial (RCT) of a multicomponent programme addressing risk factors for diabetes among American children whose race or ethnic group and socioeconomic status placed them at high risk of obesity and type 2 diabetes mellitus (T2DM). The intervention consisted of four integrated components: (1) nutrition, (2) physical activity, (3) behavioural knowledge and skills, and (4) communications and social marketing. No significant group differences were observed in the prevalence of overweight and obesity (primary outcome), but children in the intervention schools had a greater reduction in the secondary outcome of BMI SDS (–0. This was a multicomponent programme based on behavioural and ecological models, involving physical education sessions delivered by a specialist physical education teacher, additional sport and play activities outside school hours, and an educational programme.

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Institutional work is found in everyday activities discount cialis sublingual 20 mg, which can be seen to serve underlying purposes buy cheap cialis sublingual line. We build on the institutional work perspective in our case studies generic cialis sublingual 20 mg with visa. It is important to note that attempts at exercising clinical leadership are located within existing institutional arrangements. Within the context of the NHS, a great deal of institution shaping and reshaping emanates from higher-level actors, most notably NHSE and political agents; these set the direction of travel and allocate resources (financial- and legitimacy-based resources). The very origins of CCGs themselves stemmed from this source, followed by the Five Year Forward View12 and the STPs. Each of these institutional shifts was built on the assumption of the need to relocate care from hospitals to community settings. During this journey there was a move from a reliance on commissioning in a competitive market environment to large-scale planning and collaboration. Recent literature has begun to question the validity of assumptions about savings and efficiency in the shift to community care. Our research was directed at these forms of leadership. In CCGs, as with many other membership bodies, it evidently often proves difficult to fully engage the wider membership in any meaningful way. There remains a significant gap between the ambitious agendas for change set out in key policy papers and the reality on the ground of actions taken, to date, by most CCGs. Key themes emerging as requiring deeper understanding include: l the forms of influence that clinicians are actually achieving both as commissioners and providers under CCGs and associated arrangements l how leaders (managers and clinicians) are able to use the CCG as a platform and resource to bring about service redesign and, as a key part of this, the balance between formal and informal opportunities for leadership l the impact of these emerging forms of power and influence on the achievement of more integrated and effective forms of patient care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 9 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. The project proceeded through a series of sequential steps in five phases as mapped in the project Gantt chart (see Appendix 1). An extended scoping study encompassing 15 CCGs spread across England. Drawing on the results of this scoping work and on a review of the relevant literature, a national survey was designed and administered with the target population being all members of the governing boards of all 210 CCGs. This work was designed to reveal details of the processes involved in seeking meaningful service redesign through the deployment of clinical leadership and the in-depth study of a number of specific examples of attempted service redesign within these cases; the method here was to study clinical leadership in action. Drawing on the lessons learned from the case study work in phase 3, a second national survey was designed. Again, the target population was all the members of all CCG governing bodies (approximately 3100 people including accountable officers, chairpersons, GPs, secondary care doctors, nurses and lay members). A set of international comparisons enabled by sharing our results with leading international experts in other relevant health economies. The health systems chosen were those where there seemed to be some likely comparative resonance and thus the opportunity to generate further insights through the use of the perspective allowed by these comparisons. The main comparative economies selected were Canada, Germany, the Netherlands, Sweden and the USA. Phase 1 As part of the initial scoping work, studies were made of a relatively large sample of 15 CCGs and their associated hinterlands of HWBs, LAs and health-care providers. In this phase of the project, the research team were looking both outwards from focal CCGs and inwards from the perspectives of relevant others. This included gathering views from relevant stakeholder bodies such as NHSE, CQC, the Faculty of Medical Leadership and Management, the National Association of Primary Care, commissioning support units (CSUs), the London Office of CCGs, NHS clinical commissioners, clinical senates and local medical committees, LAs, HealthWatch, community services and acute hospitals (managers and consultants). Simultaneous with the work in the first phase we undertook a major literature review. This review, uniquely, not only embraced the literature on clinical leadership and leadership studies more generally, but reached out into related relevant literatures on CCGs and other earlier forms of local commissioning, and the literatures on service redesign and change in health services. The scoping phase was used to allow insight into the varied types of CCGs and to gain a sense of the range of practice across the country. Interviews were conducted with accountable officers, chairpersons and a representative sample of CCG office holders, including various clinical leads, locality leads, GP governing board members, lay members, nurses, secondary care doctors and patient and public representatives. Interviews were also conducted with LAs and with members of HWBs. This phase of the study also included observational studies of CCG board meetings and of HWBs. These were used to gain a sense of the scope of ambition and insight into which agents were engaged in what kinds of service redesign. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 11 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. PROJECT DESIGN AND METHODOLOGY The aim at this scoping stage was to capture and catalogue the range of issues. It was also designed to gain exposure to varied contexts across the country – allowing access to issues as experienced in inner and outer London, in Northern and Midland towns and cities, and in rural areas. Research team members used a common semistructured interview guide. Interviews were recorded and transcribed in most instances, depending on the wishes of the interviewees. Phase 2 The findings from this pilot phase were used to help construct the questionnaire for the first national survey of all 210 CCGs (following a merger the total later became 209) across England. In turn, the responses from that survey helped inform the selection of six core cases that were targeted for in-depth research over the ensuing 2 years. The findings from these cases helped inform the design of the final national survey that was conducted in the third year of the project. Phase 3 Central to the research design were the core cases studies. Theory building from multiple cases has 74 75, many recognised benefits – as well as challenges. Case studies enable exposure to rich data in their real-world contexts. The main case study work phase was informed by the initial scoping work and also by the results of the national survey. In the main in-depth case studies, the focus was sharpened more directly onto explorations of specific examples of service redesign and an identification of who did what in conceiving, planning, resourcing and driving the changes. So, although our point of entry was into six CCGs, the case analyses focused on eight specific service redesign attempts.

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